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Complementary or alternative in care - myths and realities GARY DENG AND BARRIE CASSILETH

Two practitioners of integrative make the case for using non- traditional alongside mainstream care – and for abandoning the term “complementary and ” as unhelpful and misleading – in this comprehensive article, which first appeared in Reviews Clinical Oncology.

magine this scene: the oncol- Data on the use of adjunctive comple- some patients, but can be selected as a ogist concludes an outline of mentary therapies for symptom con- cancer ‘treatment’ in others. Thus, the I an adjuvant treatment plan to trol is often confused by the use of the terminology and its varying interpreta- a patient who has recently been diag- convenient acronym ‘CAM’ – comple- tions interfere with accurate reporting nosed with stage III . The mentary and alternative medicine – in and hinder the accurate understand- patient asks, “Should I be on an alka- publications that fail to distinguish ing of survey data. line diet? I heard that alkalising the between alternative and complemen- The interest in therapies outside of body kills cancer cells. I’ve also heard tary modalities. The acronym is inher- mainstream oncology care is not lim- that sugar feeds cancer. Should I avoid ently imprecise. Some therapies, such ited geographically or among particular sugar? How about graviola, a herb from as , are part of mainstream segments of the population. In coun- the Amazon that is supposed to cure medical care when prescribed to tries in which modern medicine pre- cancer? Can I get during patients with deficiencies or dominates, 40–50% of patients with chemotherapy to reduce ?” taken in appropriate amounts to main- cancer use CAM therapies outside the This not-uncommon scenario brings tain general health. However, vita- mainstream.1–6 Among cancer survivors to mind pressing questions. What are mins are ‘alternatives’ when used in in the US, up to 40% used comple- these therapies and remedies that are ‘megadoses’ as a treatment for cancer, mentary or alternative therapies during not traditionally part of Western main- sometimes in lieu of mainstream care. the period following their treatment.7 stream medical care? How do we, as Similarly, ‘ for health’ might be a The 2007 National Health Interview oncologists, respond to questions about useful aid during mainstream cancer Survey showed that four in ten adults nontraditional therapies? care in some regions of the world for (38.3% of adults; 83 million individu-

CLINICAL This article was first published inNature Reviews Clinical Oncology vol. 10 no.11, and is ONCOLOGY published with permission. © 2013 Nature Publishing Group. doi:10.1038/nrclinonc.2013.125

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T’ai Chi

CURE for CANCER

als) and one in nine children less than Complementary therapies are those Academic Health Centers for Integra- 18 years of age (11.8% of children; 8.5 used to complement or use along- tive Medicine has a membership of 55 million individuals) in the US used die- side conventional methods of , esteemed academic medical centres tary supplements and various mind– whereas alternative methods refer to with medical schools, all of which have body therapy techniques.8,9 those that are used instead of known integrative medicine programmes. Largely because the CAM termi- conventional therapies. Accordingly, In this article, we summarise the nology is an admixture of unrelated the term ‘integrative therapies’ accu- data on helpful complementary ther- – often mutually contradictory – con- rately describes the complementary apies and their appropriate incorpo- cepts, the term has become outdated treatments being used in medical set- ration into cancer care (integrative and is no longer in common use. As tings alongside conventional practices. oncology), discuss nonviable alterna- accurately stated in a recent publica- Centres for integrative medicine are tive therapies and examine the patient tion: “the term ‘integrative medicine’ is being established in many academic interest in these therapies. We also fast replacing that of complementary medical centres.11 Indeed, the term provide recommendations for how and alternative medicine, or ‘CAM.’”10 CAM is rarely applied in legitimate oncology professionals can manage Another publication sums up the ter- settings, and virtually every National these issues in an -based, minology problem well: “this contro- Cancer Institute (NCI)-designated compassionate fashion that enhances versial term should be changed, since comprehensive cancer centre in the trust and rapport, strengthens the the words ‘complementary’ and ‘alter- US has a programme or department –patient relationship and native’ have different meanings and using the term ‘integrative medicine’. improves the quality of for both should not be connected by ‘and’.”11 In addition, the US Consortium of the patient and their caregivers.

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Complementary approaches emotional well-being in patients with fessionals and lasts 20–40 minutes. Mind–body therapies cancer who practice these techniques, Acupuncture is used to treat a wide Mind–body modalities focus on inter- as measured by standard validated variety of ailments, although its effi- actions between the brain, mind, instruments.19–21 cacy has been evaluated with rigor- body and behaviour with the intention Although mind–body therapies ous scientific research methodology of reducing symptoms and promot- are generally safe, their effectiveness only in the past few decades. Clinical ing health. Some of these therapies, requires instructors skilled in convey- trials have shown that the treatment such as , relaxation tech- ing appropriate technique and regular is safe and effective for several symp- niques, , yoga, T’ai Chi, practice by the patient. These help- toms experienced by patients with and have ancient ful complementary modalities can cancer.32 Indeed, a review roots; others, more recently developed, be used as part of a multidiscipli- of 11 randomised controlled trials include the likes of .12 nary approach to patient care. Major (RCTs) encompassing 1,247 patients The common goal of mind–body thera- research studies are underway to – most using sham acupuncture as pies is to reduce the effects of anxiety, elucidate the mechanisms by which controls – concluded that acupunc- , , anger, resentment, depres- mental activity exerts control over ture reduces chemotherapy-induced sion and on the patient while pro- physiological function,22–24 nausea and vomiting.33 The majority moting a sense of emotional, physical of acupuncture trials have been con- and spiritual well-being. Mind–body Acupuncture ducted to determine the of therapies do not treat cancer per se. Acupuncture, an ancient technique acupuncture in reducing pain. Recent Numerous clinical trials of variable with great contemporary interest, systematic reviews of RCTs support quality have been conducted to assess involves the placement of special the analgesic effects of acupuncture the benefits of these techniques. needles at certain body points (acu- for certain types of pain (for example, For example, systematic reviews points) a few millimetres to a few musculoskeletal pain, and meta-analyses have consistently centimetres into the skin, which can and chronic headache).34, 35 Further- shown that mind–body techniques be followed by manual manipulation more, acupuncture has shown benefit do reduce anxiety and stress, improve or the application of heat or electric in reducing radiation-induced xeros- sleep quality and overall quality of life, pulses to the needles.25 Historically, tomia,36 but mixed results in reduc- especially when used with other treat- acupuncture was thought to exert ing hot flushes experienced by women ments (such as drugs).13–17 Among its effect by regulating the flow of with breast cancer.37–39 The technique such therapies, -based (called chi or ) along merid- is possibly effective in reducing lym- stress reduction is the best studied ians in the body when inserted into phoedema in women with breast can- – an approach that focuses on devel- these acupoints.25 Although anatomi- cer who had axillary dissection.40 Both oping the patient’s objective ‘observer cal studies have shown that acupoints a of 46 RCTs and role’ for emotions, feelings and percep- tend to be located over interstitial con- a Cochrane review showed that acu- tions and creating a nonjudgmental nective tissue planes,26 current evi- puncture seems effective in treating ‘mindful state’ of conscious aware- dence does not conclusively support , although larger, rigorously ness.18 Its meditative components the claim that acupuncture points designed RCTs are warranted.41 Acu- of body scan, sitting meditation and or meridians are electrically distin- puncture has also been shown to mindful movement are taught over a guishable.27 However, substantial data relieve anxiety in a diverse patient period of weeks.18 By contrast, yoga, from neuroscientific research suggest population.42–44 T’ai Chi and qigong, which originated that the effects of acupuncture are Acupuncture is generally safe when in Asia, are less well studied, despite mediated via modulation of nervous performed by qualified practitioners. being commonly used. They com- system activity.28–31 Regulated as med- After 760,000 treatments in 97,733 bine physical movement, postures ical devices in the US, acupuncture patients receiving acupuncture in and breath control with meditation. A needles are sterile, single-use, fili- Germany, only six cases of treatment- few small trials (20–80 patients) have form, 32–36 gauge and 30–40 mm in related serious adverse events were shown a reduction in anxiety, depres- length. A typical treatment session is reported.45 The most common adverse sion and distress as well as improved provided by licensed or certified pro- effects (<5%) included minor bleeding

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T’ai or bruising and pain or unfamiliar Chi Strong pressure should be avoided sensations at the acupuncture in areas harbouring tumours or sites. In patients with cancer, metastases, or CUREto patients with acupuncture should not be bleeding tendencies.for Cases of given to those with severe neutrope- serious adverse eventsCANCER – including nia or due to their cerebrovascular accidents, ureteral higher risk of or bleed- stent displacement, haematoma, ing, or at the site of primary or nerve damage and posterior metastatic neoplasm. interosseous syndrome – have Acupuncture is not an opti- been reported, usually as a mum first-line treatment for result of exotic types of mas- symptom relief. Rather, it sage (such as application of very can be considered when strong pressure not appropriate for standard treatment is not the anatomical location) or satisfactory or not tolerated. delivered by laypeople.49,50 When In patients with severe chemo- delivered appropriately, massage therapy-induced nausea, vomit- therapy is a valuable, soothing com- ing, pain, or hot flushes Most cancer-related clinical trials plementary therapy that aids symptom in spite of optimal medical manage- of massage therapy focus on Swed- control in patients with cancer and on ment, acupuncture can be included ish massage and (foot mas- which many patients rely. as part of a multimodal management sage using specified parts of the sole plan. Although some insurance com- thought to relate to bodily organs or Alternative therapies panies do cover acupuncture treat- locations). Results have been summa- Patients might seek alternative ment provided by qualified therapists rised in two systematic reviews that therapies for a variety of reasons, for certain indications, the cost- incorporate 14 RCTs and 12 RCTs, including frustration with a lack effectiveness of acupuncture remains respectively, with some overlap.47,48 of improvement using mainstream to be determined. The control interventions used in treatments. In the past, cancer these trials include standard of care, was considered a dire with Manipulative and attention (where patients received few effective treatments; accord- body-based practices interpersonal interactions but not ingly, patients sought more-effec- Massage therapy and other manual massage therapy) or low-inten- tive, gentler treatments – real or techniques – such as Swedish massage, sity bodywork, such as light touch. imaginary.51 , , reflexology, Thai mas- Although the reviewers indicate that Today, the primary danger of sage, Ayurvedic massage, lymphatic the research methodology of most alternative therapies is that patients drainage and – are trials included in both reviews was delay or forego altogether effec- provided by massage therapists, physi- poor – for example, small sample sizes tive cancer treatment. For exam- cal therapists and occupational thera- or the lack of any attempt to control ple, instead of undergoing surgical pists.46 These practices, which evolved for nonspecific effects – the data do resection of an early-stage breast from various cultures, focus primar- support massage therapy as an effec- cancer, a patient might opt for an ily on the musculoskeletal system and tive adjunct in cancer supportive care alternative ‘natural therapy’. By connective tissues. For example, Swed- to reduce anxiety and pain.47,48 the time it becomes apparent to ish massage, the most commonly prac- Massage therapy in patients with the patient that the therapy has tised massage therapy in the West, uses cancer must be provided by certi- not controlled the growth of her five styles of long, flowing – fied massage therapists who are also cancer, it has metastasised, ren- effleurage (gliding), petrissage (knead- trained in working with patients with dering it incurable. Another risk ing), tapotement (rhythmic tapping), cancer, to minimise risk of injury. For to patients is that most alterna- friction and vibration/shaking – to example, only light-touch massage tive therapies are very costly. And manipulate soft tissues. should be provided to frail patients. as these are rarely covered by

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FACTORS CONTRIBUTING TO PATIENTS’ INTERESTS IN ALTERNATIVE THERAPIES of natural products. Furthermore, these therapies rely heavily on tes- n Poor prognosis and lack of effective treatment – willingness to try ‘anything’ timonials of purported users of the n Patient activism – wishing to search for nonmainstream treatments perceived products; the promotional materi- as unknown by oncologists als are often laden with specious n Patient empowerment – feeling like an active participant in self care scientific jargon that can appeal n Cultural values and systems – believing that anything ‘natural’ is good to laypersons, but their misleading and ‘synthetic chemicals’ are bad nature is obvious to anyone versed n Tradition of using indigenous medical systems – including traditional Chinese, in cancer . Other examples Ayurvedic and American folk medicine include ‘’ (ingestion n Conspiracy theories – believing that pharmaceutical companies suppress cura- or injection of substance containing tive ‘natural products’ out of profit motive or ) and n The internet and search engine technology – providing quick access to a vast variations of bioelectromagnetism amount of information and misinformation (subjecting the body to electromag- n Direct-to-patient – promotions by product manufacturers that netic field generated by a device), include attractive packaging and specious ‘scientific’ jargon as are various ‘energy therapies’.58 n Viral messages – medical myths, health tips and ‘cancer cure secrets’ propa- The parties that stand to profit gated by friends, relatives and others; a patient’s willingness to comply from these products use various tactics to circumvent laws and reg- ulations. They often use carefully insurance schemes, patients must apricot seeds that is not – despite worded statements or pay out of pocket for them, often its other moniker of vitamin B17 – to create the impression that the depleting their resources with the a vitamin. Although clinical stud- products can cure cancer without false hope that they are receiving ies have shown a lack of efficacy52,53 literally saying so. Or, they disasso- effective therapy. The subsequent and a risk of toxicity,54 some ciate themselves from the promoters financial havoc creates tremendous patients continue to seek and use it. by engaging in multilevel market- distress for the patient and family. In our own recent experience, one ing or ‘guerrilla marketing’ schemes. A third risk is that these therapies patient proudly displayed her vita- Although the FDA (US regulatory make false promises to desperate min B17 pill bottle during a consul- body) has investigated numerous patients – results that cannot be tation and claimed that someone told unsubstantiated claims and the Fed- delivered, representing an act of her it cured his cancer after he had eral Communications Commission deception and betrayal. As clini- been told he had only months to live. (FCC) investigates such false adver- cians, we have a moral obligation to We are certain other oncologists have tisements, the resources required dissuade patients from these use- been faced with similar situations. to gather evidence and initiate legal less therapies. Another touted cure is actions are such that they can only caesium therapy, in which patients prosecute a small number of viola- Miraculous cancer cures ingest caesium chloride (CsCl) to tors. should educate their Proponents of alternative therapies alkalinise the body. Proponents patients about why these therapies claim to produce ‘amazing’ results in claim CsCl will kill the cancer cells should be avoided. patients with cancer who have not because cancer cells “perish in an responded to conventional therapy. alkaline, high-pH, environment.”55 Anticancer diets The treatment can be as simple as a Unfortunately, ingestion of CsCl A near-universal patient question single product from an exotic source can to torsade de pointes, a concerns diet. Often patients are or derived from a ‘breakthrough dis- potentially lethal cardiac arrhyth- not satisfied with the usual dietary covery’ decades ago yet ‘suppressed’ mia.56,57 This alternative treatment advice offered by dieticians, and by mainstream medicine thereafter. can also include an elaborate regi- seek ‘anticancer’ diets – an approach For example, (also known men of special diets, detoxifica- that has spawned its own category of as laetrile) is an extract from bitter tion techniques and large doses self-help books.

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Alkaline diets a full range of nutrition. Sugar and cancer One example that is frequently cited A high-fat, low-carbohydrate ketogenic The notion that sugar ‘feeds’ cancer is in this category is the so-called alka- diet is another popular subject of inquiry. frequently cited by concerned patients. line or pH diet. This diet is similar Animal studies suggest that ketogenic Although not entirely without merit – to the concept behind caesium ther- diets induce excessive oxidative stress glucose metabolism is an active area of apy, that acidity promotes cancer and might enhance the therapeutic research in anticancer drug develop- and cancer cells cannot survive in effects of radiotherapy.59 Clinical trials ment68 – it is often exaggerated in pub- an alkaline environment. By drinking are underway to evaluate their benefits lic perception. Some patients become ‘alkaline ’, distributed from an and risks.60–62 paranoid about all sugar-containing expensive device hooked up to a fau- When responding to diet-related food, regardless of the amount. Such cet [tap], and eating ‘alkaline foods’, inquiries, oncologists might find it help- anxiety by itself is detrimental to the which happen to be mainly fresh veg- ful to point to the ‘kernels’ of truth in quality of life of patients and should etables, fruits, legumes and nuts, one the marketing materials for these pro- be avoided. Instead, patients should can ward off cancer, arthritis, grammes. The basic requirements for be advised to keep things in perspec- and other . These optimal health are to consume a variety tive: no definitive data have shown that claims disregard the fact of wholesome fresh foods and to reduce sugar promotes cancer growth. How- T’ai that the body maintains a the intake of processed food. None of ever, excessive intake of refined sugar Chi tight pH range and the radi- cal anticancer diets is unhealthy for many reasons, espe- eliminates excess that employ restrictive cially for its with metabolic acid or alkaline to CURE regimens have been syndrome, and should accordingly be preserve pH bal- for shown to significantly minimised. A small amount of refined ance. Treated CANCER improve survival. As sugar is not harmful. To meet caloric water has lit- such, patients adher- requirements, patients should con- tle buffering ing to these schemes sume complex, unrefined carbohy- capacity, there- run the risk of mal- drates and unsaturated fat (unless they fore, drinking so- nutrition. Opti- have a digestive tract condition that called alkaline water will mal caloric and precludes those foods) and avoid large not significantly affect nutrient intake amounts of foods with added sugar.69 blood pH levels. Simi- is very impor- larly, glorifying alkaline tant for patients Natural product dietary foods simply translates to be able to with- supplements to eating food that is stand their cancer thera- The use of supplements is among healthy, which provides pies. Counselling patients who the most frequently questioned sub- essential nutrients and ask about these diets also jects by patients. Over-the-coun- not an alkaline envi- provides a good opportunity ter dietary supplements available to ronment toxic to can- to put dietary advice in the patients with cancer include vitamins cer cells. context of an overall healthy lifestyle, and trace-element formulations that which also includes regular exercise.63 have well-defined constituents. Addi- Other anticancer diets The potential for physical activity tionally, botanical extracts and Many other anticancer diets with lit- to improve outcomes,64,65 including products that often contain complex tle scientific basis circulate among benefits to patients receiving pallia- compositions of many compounds, patients, including the Budwig diet, tive care,66,67 should be noted. Many some of which are unidentified, are the Gerson diet, the raw food diet leading cancer facilities have exercise also available. Indeed, botanicals, and many more.58 In addition, ‘detox’ programmes tailored to the needs of fungi and marine organisms (such as or ‘mono’ diets (such as those relying patients with cancer, with experienced sea sponges) are a rich source of ther- mainly on vegetable and fruit juice) fitness instructors who routinely work apeutic compounds that are used in can restrict or preclude important with patients across a broad range of cancer therapy; chemotherapeutic food categories that are necessary for abilities and disabilities. agents derived from natural sources –

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so-called natural products in chemical clonal gammopathy of undetermined from friends (65%), family (48%) and jargon – include the taxanes (paclitaxel significance (MGUS) to multiple mye- the media (21%),1,84 with additional is isolated from the Pacific Yew tree), loma.76 Nonetheless, the majority of the information – as well as misinforma- camptothecin (isolated from of C. available supplements has not shown a tion – being delivered via the inter- acuminata, the Chinese ‘happy tree’) reasonable possibility of meaningful net and social networks.85 The general and its analogues, vinca alkaloids (iso- clinical benefits when ingested orally. interest in complementary modali- lated from the periwinkle C. roseus) Many also carry the risk of interacting ties has increased in recent decades and numerous microbial compounds.70 with prescription or have because of increasing supportive data However, decades of research are their own detrimental effects.77–80 For on the value of complementary ther- needed to ascertain the clinical safety example, several herbs possess oestro- apies, as well as growing professional and efficacy of compounds derived gen-like activity, the intake of which is and patient acceptance of the modali- from natural sources in clinical stud- not advisable for women with oestro- ties used. Additionally, the emphasis ies. Natural products available as die- gen-receptor-positive .81 Other on wellness and survivorship, which tary supplements are not viable cancer supplements can alter drug metabo- incorporates managing long-term treatments until their efficacy has been lism, such as St John’s wort, leading to adverse effects from cancer treatment established in such studies. serum drug levels higher or lower than and reducing risk of cancer recur- Patients with cancer often ask about intended.82 Misconceptions held by rence, has enhanced general interest natural products that have been shown patients after reading news reports or in complementary modalities. to have activity against cancer in animal marketing materials need to be invali- or in vitro studies, but unconfirmed in dated in a language patients can under- Impediments to communication clinical trials. Many are readily available stand (see Table opposite). Optimal cancer care demands deal- as dietary supplements, and patients ing with issues that are important to can use them on their own, often with- Patient characteristics patients, including those that are likely out informing their physicians. In addi- Surveys indicate that patients with to be detrimental if left unaddressed. tion, patients might pursue the use of cancer who use complementary or Proper dialogue about the use and natural products marketed with ‘buzz- alternative approaches tend to be application of therapies is important. words’ such as antioxidant, immune female as well as younger, better edu- The majority of patients want to discuss booster or detox. A comprehensive cated and more affluent than those the topic with their oncologists given list of such supplements has been who do not, representing a health- the opportunity, yet nondisclosure reported.71 Patients view these prod- conscious segment of the popula- remains a problem, in part because the ucts as helpful during cancer treatment tion that is proactive in its healthcare, opportunity fails to arise.86 Addition- because of claims that the prod- that seeks health information and ally, patients have also reported being ucts protect ‘good’ cells from damage, that has the means to pay for services fearful of physician disapproval or dis- restore suppressed immune function not typically covered by insurance or interest in what they do outside of con- or remove ‘left behind’ by cancer public health schemes.1–6 Given the ventional treatment, or assume that treatment. Some of these agents might increased sophistication of patients such information is not important or hold promise in cancer prevention or and physicians in recent years, patients relevant to their cancer treatment.87,88 treatment; for example, early-phase and their oncologists increasingly pur- By contrast, physicians believe that clinical trials of polyphenols extracted sue discussions of integrative oncol- patient nondisclosure is attributable to from green tea have demonstrated ben- ogy, alert to the fact that incorporating patient of physician disapproval or efit in the treatment of chronic lym- complementary (adjunctive) therapies lack of understanding.89 As the preva- phocytic leukaemia (CLL)72 and in the into mainstream cancer treatment can lence of complementary therapy use is chemoprevention of breast cancer.73 decrease symptoms and improve over- high, initiating a discussion provides an Similarly, docosahexanoic acid (DHA, all quality of life. Furthermore, such excellent opportunity for the physician an Ω3-fatty acid) has demonstrated discussions facilitate patients in hav- to demonstrate compassion, under- positive results in breast cancer preven- ing an active role in their care.83 standing and humanity, in addition to tion74 and treatment,75 as has Patients acquire information about providing high-quality care based on in slowing progression from mono- complementary approaches primarily scientific data.

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COMMONLY ASKED QUESTIONS BY PATIENTS WITH CANCER AND EXAMPLE RESPONSES

Question, belief or statement Possible responses Examples

XYZ was reported to kill cancer cells in a What works in the test tube often does not work in humans Paclitaxel is a drug derived from the yew tree. To get the laboratory experiment. Should I take it? because the concentration used in the laboratory is so high equivalent of one dose, you would need to ingest >100 lbs that you could never achieve that level in the tumour tissue of tree bark. Taking a few capsules of the tree bark will not by ingesting the herb. do anything. Many things kill cancer cells in the test tube, but what kills If you add bleach to cancer cells, they will die. However, no the cancer cells might also hurt the healthy cells. one would drink bleach to treat cancer.

Chemotherapeutic drugs are toxins. Some ‘detox’ therapies increase the activity of the enzymes St John’s wort seems to reduce the adverse effects of I want to detoxify my body. in the to remove toxins. These enzymes can also remove chemotherapy, but was later found to also lower the level of chemotherapy drugs faster, meaning you are not getting the the active metabolite of irinotecan in the blood.77 correct dose needed.

I have so many adverse effects from my Be careful—some herbs have their own adverse effects or can Some ‘energy boosting’ herbs can raise your rate and cancer treatment. Can I take XYZ to give fight against other medications you are taking. blood pressure. Others can make your blood thinner if you me more energy or boost my immune are taking . Some might contain oestrogen- system? like substances, which might reduce your hot flushes, but can reduce the effect of the hormonal therapy you are on. Some herbs elevate your liver enzymes.

I heard that antioxidants have anticancer Antioxidants can protect DNA from damage by harmful Initial small studies suggested that vitamin E and selenium properties. Should I take them? elements in the environment, but they will not revert already- might prevent prostate cancer. Later, a randomized mutated genes back to normal. Antioxidants might have a role controlled study with tens of thousands of people showed no in cancer prevention, but they will not treat cancer; their effects cancer preventive effects and even a harmful effect.78,79 in cancer prevention have not been confirmed. A healthy diet is more important than taking individual supplements.

Antioxidants protect the body from For antioxidants to protect from chemotherapy and High-dose antioxidants given during radiotherapy have been damage caused by chemotherapy and radiotherapy the antioxidants would need to distinguish shown to reduce adverse effects during treatment, but also radiotherapy. between normal cells and cancer cells, otherwise they would might have made the cancer more likely to recur.104 protect the cancer cells as well.

Dilemmas for clinicians anticancer regimens. We believe that the answer lies in Although most patients use natu- One example is the Bill Peeples meeting patients where they are. We ral products (supplements) hoping cocktail, which is often asked about can affirm their perseverance not to to reduce the adverse effects of con- by patients with advanced-stage sar- give up, and tolerate their use of agents ventional treatment, support the body coma.90 This product contains more that are generally safe and have shown through cancer treatment or prevent than a dozen dietary supplemental some preliminary evidence of antican- cancer recurrence, other patients with ingredients that the manufacturer cer activity. At the same time, we also few or no effective treatment options claims have antiangiogenic or antiox- need to help the patient work towards might want to try anything. This des- idant properties based on laboratory accepting whatever outcome he or she peration can lead the patient to use studies, plus a few prescription medi- will eventually face, despite their best natural products that have shown cines used off-label. Such a scenario efforts and those of the treating phy- some possible anticancer activity in presents a dilemma for the oncologist sicians and caregivers. early preliminary studies. Although the faced with a patient for whom there is often begins too late in clinical prac- chances of efficacy might be extremely no effective treatment or appropriate tice.91 Instead, patients’ options, goals remote, these patients might come to . How do we provide com- and preferences should be assessed the clinic with information about the passionate care while safeguarding our early in the course of cancer treat- benefits of various elaborate, so-called patient’s best interests? ment. Personalised care of patients

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with advanced-stage cancer should be sources of facts and sound advice. of methods for the discussion of com- tailored to the diverse physical, psy- These qualified personnel can serve plementary modalities for oncolo- chological, social and spiritual conse- as valuable resources for future ques- gists.94 Together, these works provided quences of cancer for the individual.92 tions, to provide support for patients’ a framework for counselling patients Using complementary or alternative efforts, and to divert energy away from with cancer on complementary or therapies might help patients feel con- useless and potentially harmful or alternative therapies. tent that they have explored every pos- expensive approaches. Furthermore, At Memorial Sloan–Kettering Can- sible option, help them to accept the as patients gain information about cer Center, each new patient receives futility of further treatment and facili- additional symptom management an information packet that reminds tate closure. Accordingly, the treating techniques, they experience positive them to discuss any self-prescribed oncologist must take a compassion- interactions with their physicians, supplements or medications with their ate approach in accepting these deci- improve self-care skills and enhance physicians. All patients are asked at sions by the patient. Similarly, an their physical, emotional and overall each visit to disclose any herbs and effort must be made to minimise well-being.95,96 other dietary supplements they are tak- the physical, emotional ing. Patients who raise and financial bur- questions about com- dens experienced by plementary or alter- T’ai Chi the patient, discuss for native therapies that and closely moni- require discussion – tor adverse reactions and those who are on and prepare the supplements at risk of patient and family interacting with pre- for end-of-life issues. scription medicines – are referred to the Integrative oncology Integrative Medicine programmes Service for compre- Combining helpful hensive counselling. complementary ther- During the counselling apies with mainstream (see Figure opposite), cancer care to reduce physicians well versed symptoms and improve in both oncology and quality of life constitutes integrative medicine make the practice of integrative oncology. a comprehensive assessment of Many, if not most, cancer centres A structured approach to the patient’s needs and address the have established integrative oncology discussing the use of complementary issues from both the overall cancer departments or programmes to pro- or alternative medicine with patients care perspective and the patient-spe- vide complementary therapies and in general was described in 1997 and cific perspective. to counsel patients about potentially updated in 2002.97,98 Although written Practice models of integrative problematic dietary supplements and for use in the primary care or inter- oncology vary according to the patient alternative therapies. Counselling by nal medicine settings, this approach demographics and the societal envi- trained and experienced physicians might be helpful in the oncology set- ronment of the medical facility. The should include guiding patients away ting as well. A similar report focused integration is not always easy and can from potentially harmful therapies and on discussing complementary or alter- be hampered by a lack of awareness or addressing their underlying psychoso- native medicine with patients in the perceived importance by oncologists, cial or cultural needs.93,94 Referring oncology care setting.93 In 2010, a a lack of properly trained physicians patients to qualified specialists, ther- set of comprehensive communica- knowledgeable in both cancer medi- apists, counsellors or instructors con- tion guidelines was proposed on the cine and complementary therapies, a nects these individuals to appropriate basis of a systematic literature review lack of trust between physicians and

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complementary therapies practition- The resulting recommendations were Steps in advising patients who are interested ers who are not medical doctors or graded, peer-reviewed and adapted by in complementary and alternative therapies insufficient funds. An investigation of the American College of Chest Phy- six integrative oncology programmes sicians101,102 and the Society for Inte- across four continents identified sev- grative Oncology.103 These guidelines eral essential elements for a success- represent an initial effort in giving cli- ful programme: location within the nicians who might not be familiar with oncology department area, oncolo- complementary therapies evidence- gist referral to consultation with inte- based assessments of the therapies, grative oncologist, sufficient time for and when and how to incorporate integrative oncologist–oncologist com- them into the care of patients with munication, integrative practice that is cancer. With time, these national evidence based, professional comple- and international efforts in raising mentary medicine practitioners and the awareness of integrative oncol- coverage of the cost for the integrative ogy and its application in clinical oncology service.99 care would improve the overall care For busy oncologists, staying of cancer patients. abreast of new complementary medi- cine research results and of the ever- Conclusions expanding world of alternatives to Complementary or alternative medi- mainstream cancer treatment is diffi- cine are topics that patients with can- cult. However, many excellent contin- cer are highly interested in and also uing education materials are available find quite confusing. Safe and bene- from reputable sources. In addition, ficial complementary therapies should the knowledge and expertise available be integrated into regular cancer care from integrative oncology colleagues to improve patient quality of life and can be extremely helpful, especially outcome. However, patients should be those dual-trained in mainstream steered away from alternative cancer oncology and integrative medicine. therapies that are risky and do not have National-level and international-level clinical value. Integrative oncology efforts can provide helpful informa- combines complementary therapies tion to practising oncologists. A mul- with mainstream care, trying to opti- tidisciplinary nonprofit organisation – mise the patient’s physical, psycho- the Society for Integrative Oncology logical and spiritual well-being, taking – was formed by clinicians, research- into consideration the individual’s val- ers and patient advocates to provide a ues and priorities in life. A robust inte- platform for the advancement of evi- grative oncology programme should be dence-based, comprehensive, integra- part of any high-quality cancer care tive healthcare to improve the of institution, as is the case for virtually people affected by cancer.100 Using all NCI-designated comprehensive the standard methodology for devel- cancer centres. By understanding and opment of a practice guideline, which addressing issues our patients feel are consists of systematic review of cur- important, compassionate care can be References Details of the references cited in this article can rent literature and multiple rounds tailored to each patient, and oncology be found at www.cancerworld.com of peer reviews, the group evaluated will reach the noble goal of treating the strength of the evidence for com- each patient as a person with cancer, Author affiliations Gary Deng and Barrie Cassileth, Integrative mon complementary therapies, as rather than treating only the cancer in Medicine Service, Memorial Sloan-Kettering well as any potential risks or burdens. a patient. n Cancer Center, New York

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